• Aditi Gupta, Sean Kumer, and Bruce Kaplan.
• aDepartment of Nephrology bDepartment of Surgery, Center for Transplantation cUniversity of Kansas Medical Center, Kansas City, Kansas, USA.
• Curr Opin Organ Transplant. 2014 Dec 1;19(6):552-7.

Purpose Of ReviewVascularized composite tissue allografts (CTAs) provide excellent restorative options for patients with limb loss and other deformities. Acute rejection remains common with CTA and immunosuppression is used in an attempt to prevent rejection. This has created ethical debates regarding the use of intensive immunosuppression for a nonlife-saving procedure. This highlights the need for newer immunosuppressive strategies for CTA, which are described in this review.Recent FindingsRecent studies have looked into immunomodulation and tolerance to decrease toxicity of immunosuppression. Both strategies have had some success but have their own limitations. Although immunomodulation and decrease in immunosuppression decreases toxicity, it has been associated with higher rates of rejection. Induction of tolerance has achieved some initial success, but the initial conditioning regimens are associated with significant morbidity.SummaryAlthough recent advancements have been made in the immunosuppressive strategies in CTA, the ideal immunosuppression strategy with low toxicity and infection risk but with the ability to prevent acute and chronic rejection is yet to be discovered.

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